Is malnutrition associated with postoperative complications after cardiac surgery?

BACKGROUND AND AIM: Malnutrition is the central component of frailty that has an adverse influence on the prognosis of patients undergoing cardiac surgery. The relationship between malnutrition and postoperative complications was evaluated in a retrospective cohort study. METHODS: In 287 patients undergoing elective cardiac surgery, nutritional status was assessed by using the Geriatric Nutritional Risk Index (GNRI). Then the patients were divided into a malnutrition group (GNRI <91) and a nonmalnutrition group (GNRI ≥91), after which the postoperative course was compared. RESULTS: There were 51 patients (17.8%) in the malnutrition group. Nine patients died after surgery and the operative mortality rate was significantly higher in the malnutrition group than the nonmalnutrition group (five deaths [9.8%] vs four deaths [1.8%]; P = .003). In addition, the duration of intensive care unit stay and hospital stay were both significantly longer in the malnutrition group compared with the nonmalnutrition group. Multivariate analysis showed that malnutrition was an independent predictor of hospitalization for longer than 1 month (odds ratio [OR]: 3.428; 95% confidence interval [CI]:1.687-6.964; P = .001) and a postoperative bedridden state (OR: 7.377; 95% CI:1.874-29.041; P = .004). CONCLUSIONS: Preoperative evaluation of the nutritional status using the GNRI seems to be valuable for predicting the risk of postoperative complications.

Pasteurella multocida Infective Endocarditis.

Pasteurella multocida, a Gram-negative facultative anaerobic coccobacillus, is a common oral flora of dogs and cats. P. multocida often causes infection in humans after animal bites and scratches, and human pasteurellosis is generally a locoregional infection. Systemic complications, particularly endocarditis, are very rare, except in immunodeficient patients. Endocarditis caused by P. multocida can have severe outcomes; hence, surgical treatment is often required. Here, a case is described of endocarditis caused by P. multocida in a previously healthy patient with no history of animal injury, which was successfully treated with surgery.

A Patient with Aortic Arch Aneurysm Perforating the Left Pulmonary Artery.

An aortic arch aneurysm rarely perforates the pulmonary artery, but once this occurs symptoms of heart failure may develop rapidly and result in a serious course. Here, we report such a case that was treated with life-saving emergency surgery. The patient was an 86-year-old man in whom aortic arch aneurysm had been pointed out 8 years earlier, but left untreated. In January 2014, dyspnea developed and he visited the emergency unit of our hospital. Continuous murmur was heard on auscultation, and aorta-pulmonary artery shunt was noted on transthoracic echocardiography. Chest computed tomography revealed a giant aortic arch aneurysm of size 106 mm that had perforated the left pulmonary artery (LPA). Emergency surgery was performed for a diagnosis of acute heart failure associated with perforation of the LPA by a giant aortic arch aneurysm. The postoperative course was favorable, and the patient was discharged with independent walking on postoperative day 28.

Efficacy of Tolvaptan in Patients with Volume Overload after Cardiac Surgery.

BACKGROUND: The vasopressin type 2 receptor antagonist tolvaptan (TLV) has recently become available for treating congestion. However, there is no evidence confirming the efficacy of TLV for patients with volume overload after cardiac surgery. Here, we retrospectively studied the efficacy of TLV in patients with volume overload after cardiac surgery. METHODS: We enrolled a total of 39 patients who had volume overload after cardiac surgery and who were treated with our protocol of body fluid management. The primary endpoint of this study was to evaluate the hospitalization period, while the secondary endpoints were to estimate adverse events such as hypotension, electrolyte abnormality, presence or absence of renal dysfunction and liver damage, and the incidence of atrial fibrillation (AF). RESULTS: The hospitalization period of the T (TLV) and C (furosemide and spironolactone) groups was 12.3 ± 2.6 days and 14.7 ± 4.4 days, respectively (P = .044), the mean urine volume was 2761.5 ± 850.3 mL/day and 2205.2 ± 598.5 mL/day, respectively (P = .024), and the incidence of postoperative AF after diuretics administration was 2/19 (11%) and 9/17 (52%), respectively. CONCLUSION: TLV successfully and rapidly improved organ congestion without causing hemodynamic abnormalities (hypotension, arrhythmia development), electrolyte abnormality, liver damage or renal dysfunction, thus significantly reducing the period of hospitalization.

[Early Results of Minimally Invasive Cardiac Surgery (MICS) Mitral Valve Surgery with 51 Cases].

BACKGROUND: Minimally invasive cardiac surgery of the mitral valve (MICS-MV) has become the routine approach to mitral valve disease in some centers. We reported early results of 51 cases of MICS-MV. METHOD: The preoperative variables, intraoperative date and postoperative outcomes of patients undergoing MICS-MV and conventional surgery of the mitral valve were collected from January 2013 to August 2014. RESULTS: Aortic cross clamp and cardio-pulmonary bypass( CPB) time were longer in this series than in the conventional median sternotomy. We experienced complications and 2 patients required mitral valve replacement (MVR) due to failure of repair in initial MICS cases. One case of the patients with infective endocarditis was performed conversion of from MICS to a median sternotomy due to left ventricle(LV) rupture. CONCLUSION: The early-time outcomes in these patients are acceptable. We think that large number of MICS-MV operations are required to overcome the learning curve.

[Penetrating injury of the right ventricle by nail gun; report of a case].

A 43-year-old man accidentally shot himself with a nail gun. He was seen in the other hospital. Chest computed tomography showed nail penetrating the thorax, and a small amount of pericardial effusion. He was transferred to our hospital and underwent an operation on emergency. After sternotomy and pericardiotomy, the nail was found to reach the right ventricle, and was almost pulled out. The nail was removed and the right ventricle was repaired with felt 4-0 mattress sutures. His postoperative course was uneventful and discharged 7 days after the accident. Because penetrating cardiac injuries often cause cardiac tamponade, prompt diagnosis and emergency surgical repair are required. We report a case of nail penetration injury of the right ventricle with a review of the pertinent literature.

Medical treatment for acute Type A aortic dissection.

Six patients with acute Type A aortic dissection were medically treated due to advanced age, patient refusal and comorbidity despite surgical indication. Computed tomography after onset revealed a thrombosed false lumen in 3 patients and a patent false lumen with flap in 3 patients. All patients were stable during admission except 1 patient who presented with shock. After admission, treatment including strict control of systolic blood pressure was started according to a predetermined treatment strategy. All patients had no significant complications during hospitalization. All patients survived and returned to their usual activities. Medical treatment for stable elderly patients is a possible therapeutic option for acute Type A aortic dissection.

A floating thrombus in the ascending aorta complicated by acute myocardial infarction.

A 37-year-old male was transferred to our hospital with a diagnosis of acute myocardial infarction and a mass in the ascending aorta. Echocardiography revealed dyskinesia on the left ventricular apex and a floating mass lesion just above the aortic valve. Acute myocardial infarction was considered to be caused by embolism from the floating mass in the ascending aorta. Emergency surgery was successfully performed and histological examination showed the extirpated mass in the ascending aorta was thrombus. The patient has been well on oral anticoagulant and no recurrence has been seen on echocardiogram 4 years after the operation.

Gender-linked impact of epicardial adipose tissue volume in patients who underwent coronary artery bypass graft surgery or non-coronary valve surgery.

BACKGROUND: Traditional and non-traditional risk factors for atherosclerotic cardiovascular disease (ASCVD) are different between men and women. Gender-linked impact of epicardial adipose tissue volume (EATV) in patients undergoing coronary artery bypass grafting (CABG) remains unknown. METHODS: Gender-linked impact of EATV, abdominal fat distribution and other traditional ASCVD risk factors were compared in 172 patients (men: 115; women: 57) who underwent CABG or non-coronary valvular surgery (non-CABG). RESULTS: In men, EATV, EATV index (EATV/body surface area) and the markers of adiposity such as body mass index, waist circumference and visceral fat area were higher in the CABG group than in the non-CABG group. Traditional ASCVD risk factors were also prevalent in the CABG group. In women, EATV and EATV index were higher in the CABG group, but other adiposity markers were comparable between CABG and non-CABG groups. Multivariate logistic regression analysis showed that in men, CABG was determined by EATV Index and other ASCVD risk factors including hypertension, dyslipidemia, adiponectin, high sensitive C-reactive protein (hsCRP) and type 2 diabetes mellitus (Corrected R2 = 0.262, p < 0.0001), while in women, type 2 diabetes mellitus is a single strong predictor for CABG, excluding EATV Index (Corrected R2 = 0.266, p = 0.005). CONCLUSIONS: Our study found that multiple risk factors, including epicardial adipose tissue volume and traditional ASCVD factors are determinants for CABG in men, but type 2 diabetes mellitus was the sole determinant in women. Gender-specific disparities in risk factors of CABG prompt us to evaluate new diagnostic and treatment strategies and to seek underlying mechanisms.

The life-threatening complication of a vascular graft rupture early after a thoracic aortic replacement.

A 74-year old male presented with a dilatation of the thoracic aorta late after an acute aortic dissection. Computed tomography (CT) showed chronic dissecting aortic aneurysms just below the distal aortic arch. The total descending thoracic aorta was surgically replaced. Four weeks later, a massive bloody effusion developed in the right thorax and a subsequent CT scan revealed an extravasation of the contrast material out of the vascular prosthesis. Emergency surgery disclosed bleeding from a small vascular graft rupture and a successful repair was performed.